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Long-Term Outcome of Myectomy Associated With Secondary Mitral Valve Chordal Cutting in Obstructive Hypertrophic
Paolo Ferrazzi1, Paolo Spirito2, Irene Binaco3
1Centro per la Cardiomiopatia Ipertrofica e le Cardiopatie Valvolari, Policlinico di Monza, Monza, Italy; International Heart School Foundation, Bergamo, Italy.
Insights
Septal myectomy with mitral chord cutting offers excellent long-term outcomes for obstructive hypertrophic cardiomyopathy (HCM) patients. This surgical approach provides sustained symptom relief and survival comparable to the general population.
Area of Science:
- Cardiology
- Cardiac Surgery
- Genetics
Background:
- Obstructive hypertrophic cardiomyopathy (HCM) management is evolving with new cardiac myosin inhibitors.
- Surgery remains a vital option for advanced, symptomatic HCM patients unresponsive to medical therapy.
- Previous short-term studies showed positive results for septal myectomy combined with mitral chord cutting.
Purpose of the Study:
- To evaluate the long-term clinical and hemodynamic outcomes of septal myectomy combined with anterior mitral leaflet secondary chord cutting in obstructive HCM patients.
Main Methods:
- A cohort of 350 consecutive obstructive HCM patients underwent the procedure over 5 years.
- Median follow-up was 5.6 years.
- Surgical mortality, overall survival, functional status (NYHA), and echocardiographic parameters were assessed.
Main Results:
- Surgical mortality was 0.6% (2 deaths).
- 6-year overall survival was 96%, similar to the age- and sex-matched general population.
- At follow-up, 98% of patients were in NYHA functional class I or II, with no residual left ventricular outflow tract obstruction or significant mitral regurgitation.
Conclusions:
- Septal myectomy with mitral chord cutting demonstrates excellent and durable long-term clinical and hemodynamic results in obstructive HCM.
- This surgical strategy enhances the viability of myectomy centers and expands surgical options for severe, medically refractory HCM.
- The procedure leads to significant improvement in symptoms and hemodynamic profiles, comparable to medical management outcomes.
Background:
The recent introduction of cardiac myosin inhibitors has modified the therapy of left ventricular outflow obstruction in patients with hypertrophic cardiomyopathy (HCM) and is raising uncertainties regarding the future role of surgery in the management of obstructive HCM. However, it is likely that a proportion of patients will continue to present with advanced, highly symptomatic HCM, despite medical therapy, and require surgical intervention. We previously reported the short-term results of cutting anterior mitral leaflet secondary chordae in combination with septal myectomy in patients with obstructive HCM. This operative approach has shown excellent results in several short-term studies from our and other centers. However, no data are currently available regarding the long-term outcome of this novel surgical procedure.
Objectives:
The study sought to investigate the long-term results of myectomy associated with chordal cutting.
Methods:
Long-term results were assessed in 350 consecutive patients with obstructive HCM who underwent this operation at our center over a 5-year period. Median follow-up was 5.6 years (Q1-Q3: 4.2-6.3 years).
Results:
Including 2 in-hospital deaths (surgical mortality 0.6%), 6-year overall survival after surgery was 96% and did not differ from that of the general Italian population matched for age and sex (P = 0.331). Follow-up information was available in 344 (99%) patients. At the most recent evaluation, 271 (79%) patients were asymptomatic in NYHA functional class I, 65 (19%) were in NYHA functional class II, and 8 (2%) were in NYHA functional class III. During follow-up, there were 14 deaths, 6 of which were unrelated to HCM. At most recent echocardiographic evaluation, ≥95% of patients had no residual left ventricular outflow gradient, clinically significant mitral regurgitation, or impaired systolic function.
Conclusions:
Our results show that cutting thickened and/or retracted secondary chordae of the anterior mitral leaflet in association with septal myectomy has excellent long-term clinical and hemodynamic results in patients with obstructive HCM. These findings may further increase the number of myectomy referral centers and the availability of the surgical option for severely symptomatic HCM patients unresponsive to medical treatment.
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